Infant And Toddler Medical History Form

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INFANT/TODDLER HISTORY FORM
Child’s full name
Date
Birth date
SEX: M/F
Parent’s name(s)
Parent’s Address(s) & Phone(s)
Parent’s Email address: ____________________________________________________
Have you noticed anything wrong with your child’s eyes?
Does either parent have any type of eye vision problems?
List all illnesses and age at the time if illness?
What allergies does your child have?
Is there any reason that your child should not have eye drops?
Is your child currently being treated for anything? If so, what?
What specific problem brought you in today?
Were there any complications during your pregnancy?
What medications are being administered?
Was the child born at full term?
Was delivery normal?
What was the infant’s APGAR score?
What was the birth weight?
Do you believe that your child is developing normally?
Have you noticed the child favoring one eye or seen one eye turning? If so, when?
Has the child suffered any high fevers or has the child encountered trauma, particularly
around the head?
Describe any concern you have about your child’s health and vision.
Primary care physician’s name, address and phone number.
:
Family History
_______Diabetes
Glaucoma
Eye turn or lazy eye
_______Heart Disease
Eye Disease
Blindness
I authorize the release of medical information necessary for the payment or processing of services and
materials provided by my optometrist. Due to increasing costs we ask that services be paid for at time of
visit and deposits be made on lab orders with payment in full at delivery. We will fill out your insurance
forms and reimburse you if payment is made. Thank you. (Exceptions: Medicare, Medicaid, and certain
vision plans)
Sign:
Date:

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